Chapter 34. Skin Integrity and Wound Care My Nursing Test Banks

Chapter 34. Skin Integrity and Wound Care

Multiple Choice

Identify the choice that best completes the statement or answers the question.

____ 1. What is the function of the stratum corneum?

1)

Provides insulation for temperature regulation

2)

Provides strength and elasticity to the skin

3)

Protects the body against the entry of pathogens

4)

Continually produces new skin cells

____ 2. Skin integrity and wound healing are compromised in the client who takes blood pressure medications because antihypertensives:

1)

Can cause cellular toxicity.

2)

Increase the risk of ischemia.

3)

Delay wound healing.

4)

Predispose to hematoma formation.

____ 3. What is the primary difference between acute and chronic wounds? Chronic wounds:

1)

Are full-thickness wounds, but acute wounds are superficial.

2)

Result from pressure, but acute wounds result from surgery.

3)

Are usually infected, whereas acute wounds are contaminated.

4)

Exceed the typical healing time, but acute wounds heal readily.

____ 4. A patient with quadriplegia presents to the outpatient clinic with an ischial wound that extends through the epidermis into the dermis. When documenting the depth of the wound, how would the nurse classify it?

1)

Partial-thickness wound

2)

Penetrating wound

3)

Superficial wound

4)

Full-thickness wound

____ 5. A patient underwent abdominal surgery for a ruptured appendix. The surgeon did not surgically close the wound. The wound healing process described in this situation is:

1)

Primary intention healing.

2)

Secondary intention healing.

3)

Tertiary intention healing.

4)

Approximation healing.

____ 6. When teaching a patient about the healing process of an open wound after surgery, which of the following points would the nurse make?

1)

The patient will need to take antibiotics until the wound is completely healed.

2)

Because the patients wound was left open, the wound will likely become infected.

3)

The patient will have more scar tissue formation than for a wound closed at surgery.

4)

The patient should expect to remain hospitalized until complete wound healing occurs.

____ 7. What is the primary goal that the nurse should establish for a patient with an open wound?

1)

The wound will remain free of infection throughout the healing process.

2)

Client completes antibiotic treatment as ordered.

3)

The wound will remain free of scar tissue at healing.

4)

Client increases caloric intake throughout the healing process.

____ 8. While assessing a new wound, the nurse notes red, watery drainage. What type of drainage will the nurse document this as?

1)

Sanguineous

2)

Serosanguineous

3)

Serous

4)

Purosanguineous

____ 9. Three days ago a patient had cardiac surgery to bypass three occlusions of his coronary arteries. Veins for the bypass were harvested from his right leg. He informs the nurse that his leg is warm and tender in his right calf. The nurse notes a 3-cm periwound erythema and swelling at the distal end of the incision. Staples are intact along the incision, and there is no drainage. Vital signs are stable. The nurse would suspect that the patient has what kind of complication?

1)

Deep vein thrombosis

2)

Dehiscence of the wound

3)

Internal bleeding

4)

Infection at the incisional site

____ 10. Which of the following describes the difference between dehiscence and evisceration?

1)

With dehiscence, there is a separation of one or more layers of wound tissue; evisceration involves the protrusion of internal viscera from the incision site.

2)

Dehiscence is an urgent complication that requires surgery as soon as possible; evisceration is not as urgent.

3)

Dehiscence involves the protrusion of internal viscera from the incision site; with evisceration, there is a separation of one or more layers of wound tissue.

4)

Dehiscence involves rupture of subcutaneous tissue; evisceration involves damage to dermal tissue.

____ 11. The nurse will know that the plan of care for the diabetic client with severe peripheral neuropathy is effective if the client

1)

begins an aggressive exercise program.

2)

follows a diet plan of 1,000 calories per day.

3)

is fitted for deep-depth diabetic footwear.

4)

remains free of foot wounds.

____ 12. Pressure ulcers are directly caused by which of the following conditions at the site?

1)

Compromised blood flow

2)

Edema

3)

Shearing forces

4)

Inadequate venous return

____ 13. A patient hospitalized in a long-term rehabilitation facility is immobile and requires mechanical ventilation with a tracheostomy. She has a pressure area on her coccyx measuring 5 cm by 3 cm. The area is covered with 100% eschar. What would the nurse identify this as?

1)

Stage II pressure ulcer

2)

Stage III pressure ulcer

3)

Stage IV pressure ulcer

4)

Unstageable pressure ulcer

____ 14. A client developed a stage IV pressure ulcer to his sacrum 6 weeks ago, and now the ulcer appears to be a shallow crater involving only partial skin loss. What would the nurse now classify the pressure ulcer as?

1)

Stage I pressure ulcer, healing

2)

Stage II pressure ulcer, healing

3)

Stage III pressure ulcer, healing

4)

Stage IV pressure ulcer, healing

____ 15. A patient has underlying cardiac disease and requires careful monitoring of his fluid balance. He also has a draining wound. Which of the following methods for evaluating his wound drainage would be most appropriate for assessing fluid loss?

1)

Draw a circle around the area of drainage on a dressing.

2)

Classify drainage as less or more than the previous drainage.

3)

Weigh the patient at the same time each day on the same scale.

4)

Weigh dressings before they are applied and after they are removed.

____ 16. A patient had a CVA (stroke) 2 days ago, resulting in decreased mobility to her left side. During the assessment, the nurse discovers a stage I pressure area on the patients left heel. What is the initial treatment for this pressure ulcer?

1)

Antibiotic treatment for 2 weeks

2)

Normal saline irrigation of the ulcer daily

3)

Dbridement to the left heel

4)

Elevation of the left heel off the bed

____ 17. Why is the information obtained from a swab culture of a wound limited?

1)

A positive culture does not necessarily indicate infection because chronic wounds are often colonized with bacteria.

2)

A negative culture may not indicate infection because chronic wounds are often colonized with bacteria.

3)

Most wound infections are viral, so the swab culture would not be indicative of a wound infection.

4)

A swab culture result does not include bacterial sensitivity information necessary to provide treatment.

____ 18. For the client with a stage IV pressure ulcer, what would an applicable patient goal/outcome be?

1)

Client will maintain intact skin throughout hospitalization.

2)

Client will limit pressure to wound site throughout treatment course.

3)

Wound will close with no evidence of infection within 6 weeks.

4)

Wound will improve prior to discharge as evidenced by a decrease in drainage.

____ 19. A man was involved in a motor vehicle accident yesterday. He is to be sedated for over 2 weeks while breathing with the assistance of a mechanical ventilator. Which of the following would be an appropriate nursing diagnosis for him at this time?

1)

Risk for Infection related to subcutaneous injuries

2)

Risk for Impaired Skin Integrity related to immobility

3)

Impaired Tissue Integrity related to ventilator dependency

4)

Impaired Skin Integrity related to ventilator dependency

____ 20. What intervention would be most appropriate for a wound with a beefy red wound bed?

1)

Mechanical dbridement

2)

Autolytic dbridement

3)

Dressing to keep the wound moist and clean

4)

Removal of devitalized tissue and a sterile dressing

____ 21. A patient has a stage II pressure ulcer on her right buttock. The ulcer is covered with dry, yellow slough that tightly adheres to the wound. What is the best treatment the nurse could recommend for treating this wound?

1)

Dry gauze dressing changed twice daily

2)

Nonadherent dressing with daily wound care

3)

Hydrocolloid dressing changed as needed

4)

Wet-to-dry dressings changed 3 times a day

____ 22. The nurse would know care for a stage II pressure ulcer is achieving the desired goal when:

1)

The ulcer is completely healed with minimal scarring.

2)

The patient reports no pain at the site.

3)

A minimal amount of drainage is noted.

4)

The wound bed contains 100% granulated tissue.

____ 23. Your patient has a deep wound on the right hip, with tunneling at the 8 oclock position extending 5 cm. The wound is draining large amounts of serosanguineous fluid and contains 100% red beefy tissue in the wound bed. Of the following, which would be an appropriate dressing choice?

1)

Alginate dressing

2)

Dry gauze dressing

3)

Hydrogel

4)

Hydrocolloid dressing

____ 24. Of the following, which is the best choice for performing wound irrigation?

1)

Water jet irrigation

2)

35-cc syringe with a 19-gauge angiocatheter

3)

5-cc syringe with a 23-gauge needle

4)

Bulb syringe

____ 25. Your patient has multiple open wounds that require treatment. When performing dressing changes, you should:

1)

Remove all of the soiled dressings before beginning wound treatment.

2)

Cleanse wounds from most contaminated to least contaminated.

3)

Treat wounds on the patients side first, then the front and back of the patient.

4)

Irrigate wounds from least contaminated to most contaminated.

____ 26. A patient had abdominal surgery. The incision has been closed by primary intention, and the staples are intact. To provide more support to the incision site and decrease the risk of dehiscence, it would be appropriate to apply which of the following?

1)

Steri-Strips

2)

Abdominal binder

3)

T-binder

4)

Paper tape

____ 27. A patient has an area of nonblanchable erythema on his coccyx. The nurse has determined this to be a stage I pressure ulcer. What would be the most important treatment for this patient?

1)

Transparent film dressing

2)

Sheet hydrogel

3)

Frequent turn schedule

4)

Enzymatic dbridement

____ 28. When applying heat or cold therapy to a wound, what should the nurse do?

1)

Leave the therapy on each area no longer than 15 minutes.

2)

Leave the therapy on each area no longer than 30 minutes.

3)

When using heat, ensure the temperature is at least 135F (57.2C) before applying it.

4)

When using cold, ensure the temperature is less than 32F (0C) before applying it.

____ 29. A patient has a contaminated right hip wound that requires dressing changes twice daily. The surgeon informs the nurse that when the wound heals a little more he will suture it closed. The nurse recognizes that the surgeon is using which form of wound healing?

1)

Primary intention

2)

Regenerative healing

3)

Secondary intention

4)

Tertiary intention

____ 30. What is a common characteristic of aging skin?

1)

Increased permeability to moisture

2)

Diminished sweat gland activity

3)

Reduced oxygen-free radicals

4)

Overproduction of elastin

____ 31. Which client does the nurse recognize as being at greatest risk for pressure ulcers?

1)

Infant with skin excoriations in the diaper region

2)

Young adult with diabetes in skeletal traction

3)

Middle-aged adult with quadriplegia

4)

Older adult requiring use of assistive device for ambulation

____ 32. The nurse working in the emergency department is preparing heat therapy for one of the patients in the unit. Which one is it most likely to be? Choose all that apply.

1)

Is actively bleeding

2)

Has swollen, tender insect bite

3)

Has just sprained her ankle

4)

Has lower back pain

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

____ 1. Select the process(es) that occur(s) during the inflammatory phase of wound healing. Choose all that apply.

1)

Granulation

2)

Hemostasis

3)

Epithelialization

4)

Inflammation

____ 2. What are two risk assessment tools used in the United States to evaluate a patients risk for skin problems? Choose all that apply.

1)

FLACC scale

2)

Waterlow scale

3)

Braden scale

4)

Norton scale

____ 3. Which of the following are examples of nonselective mechanical dbridement methods? Choose all that apply.

1)

Wet-to-dry dressings

2)

Sharp dbridement

3)

Whirlpool

4)

Pulsed lavage

____ 4. Why is an accurate description of the location of a wound important? Choose all that apply.

1)

Influences the rate of healing

2)

Determines the appropriate treatment choice

3)

Will affect the frequency of dressing changes

4)

Affects patient movement and mobility

Completion

Complete each statement.

1. Exposure to moisture leads to ____________________ of the skin, which increases the likelihood of skin breakdown.

2. ____________________ is total separation of the layers of a wound with internal viscera protruding through the incision.

Chapter 34. Skin Integrity and Wound Care

Answer Section

MULTIPLE CHOICE

1. ANS: 3

The stratum corneum is the outermost layer of the epidermis and is composed of numerous thicknesses of dead cells. Functioning as a barrier to the environment, it restricts water loss, prevents entry of fluids into the body, and protects the body against the entry of pathogens and chemicals. The subcutaneous layer is composed of adipose and connective tissue that provide insulation, protection and an energy reserve (adipose). The dermis is composed of irregular fibrous connective tissue that provides strength and elasticity to the skin. The stratum germinativum is the innermost layer of the skin that produces new cells, pushing older cells toward the skin surface.

PTS: 1 DIF: Moderate REF: V1, p. 831

KEY: Client need: PHSI | Cognitive level: Comprehension

2. ANS: 2

Blood pressure medications decrease the amount of pressure required to occlude blood flow to an area, creating a risk for ischemia. Chemotherapeutic agents delay wound healing because of their cellular toxicity. Anticoagulants can lead to extravasation of blood into subcutaneous tissue, predisposing to hematoma formation with minimal pressure or injury.

PTS: 1 DIF: Difficult REF: V1, p. 833

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension

3. ANS: 4

The length of time for healing is the determining factor when classifying a wound as acute or chronic. Acute wounds are expected to be of short duration. Wounds that exceed the anticipated length of recovery are classified as chronic wounds.

PTS: 1 DIF: Easy REF: V1, pp. 834-835

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis

4. ANS: 1

Partial-thickness wounds extend through the epidermis into the dermis. Superficial wounds involve only the epidermal layer of skin. Full-thickness wounds extend into the subcutaneous tissue and beyond. Penetrating is a descriptor sometimes added to indicate that the wound includes internal organs.

PTS: 1 DIF: Easy REF: V1, p. 836

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application

5. ANS: 2

Secondary intention healing occurs when a wound is left open, and it heals from the inner layer to the surface by filling in with beefy red granulation tissue. Primary intention healing occurs when a wound is surgically closed. Tertiary intention healing occurs when a wound that was previously left open to heal by secondary intention is closed by joining the margins of granulation tissue. Approximation is another word for the joining of wound edges.

PTS: 1 DIF: Moderate REF: V1, p. 836

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension

6. ANS: 3

Because the wound edges are not approximated, more scar tissue will form. Although open wounds are more prone to infection, this is not an expected outcome, and antibiotics would not necessarily be needed. A patient with an open wound should not expect an extended hospital stay if wound care can be provided in the home or an outpatient setting.

PTS: 1 DIF: Difficult REF: V1, p. 836

KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application

7. ANS: 1

Wounds healing by secondary intention are more prone to infection; therefore, the primary goal would be to prevent infection. Antibiotics may not be necessary, and the nurse can expect the formation of scar tissue in this particular situation. There is no evidence presented that the patient needs to increase caloric intake.

PTS: 1 DIF: Moderate REF: V1, p. 836

KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Synthesis

8. ANS: 2

Serosanguineous drainage, a combination of bloody and serous drainage, is most commonly seen with new wounds. Serous drainage is straw-colored, and sanguineous drainage is bloody. Purosanguineous drainage is pus that is red tinged.

PTS: 1 DIF: Easy REF: V1, p. 839

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension

9. ANS: 1

Deep vein thrombosis (DVT) is a clot in the veins that are deep under the muscles of the leg. DVT can occur after surgery, after lengthy bed rest, or after trauma. Symptoms include pain, warmth, redness, and swelling of the leg. Dorsiflexion of the foot (pulling toes forward) and Pratts sign (squeezing calf to trigger pain) have not been found to be useful in diagnosing DVT. Dehiscence is the rupture of a suture line, whereas evisceration is the protrusion of internal organs through the rupture. Internal bleeding is a wound-healing complication associated with hematoma formation, pain, hypotension, and tachycardia. Infection is a complication of wound healing that causes warmth, pain, inflammation of the affected area, and changes in vital signs (i.e., elevated pulse and temperature).

PTS: 1 DIF: Difficult REF: V1, p. 842

KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis

10. ANS: 1

With dehiscence there is a separation of one or more layers of wound tissue, whereas evisceration involves the protrusion of internal viscera from the incision site. Evisceration is an urgent complication usually requiring immediate surgical intervention.

PTS: 1 DIF: Moderate REF: V1, pp. 839-840

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis

11. ANS: 4

Diabetic clients experiencing difficulty with blood sugar control are prone to the development of peripheral neuropathy, which results in decreased sensation in the feet and lower extremities. Decreased sensation in the feet places the client at increased risk for development of wounds or pressure ulcers in the feet. The nurse will know his plan of care is effective when the clients feet remain free of wounds. An aggressive exercise program would not be appropriate for a client with severely diminished sensation in the feet. Similarly, a 1,000-calorie diet would be inadequate for most clients. Being fitted for diabetic footwear is an intervention rather than a goal.

PTS: 1 DIF: Difficult

REF: V1, p. 842; higher-order item implied from text

KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Synthesis

12. ANS: 1

Pressure ulcers are caused by unrelieved pressure that compromises blood flow to an area, resulting in ischemia (inadequate blood supply) in the underlying tissue. Friction and shear are extrinsic factors affecting skin integrity, which increases the risk of a client developing a pressure ulcer but is not the direct cause. Inadequate arterial blood flow to an area due to pressure causes the development of a pressure ulcer. Edema leads to compromised skin and tissue integrity, which is more prone to pressure injury.

PTS: 1 DIF: Difficult REF: V1, p. 841 | V2, p. 830

KEY: Client need: HPM | Cognitive level: Comprehension

13. ANS: 4

An eschar is a black, leathery covering made up of necrotic tissue. An ulcer covered in eschar cannot be classified using a staging method because it is impossible to determine the depth.

PTS: 1 DIF: Moderate REF: V1, p. 844 | V2, p. 830

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application

14. ANS: 4

Reverse staging is not done because as the ulcer heals with granulation tissue and becomes shallower, the lost muscle, subcutaneous fat, and dermis are not replaced. Pressure ulcers maintain their original staging classification throughout the healing process but are accompanied by the modifier healing.

PTS: 1 DIF: Moderate REF: V1, p. 841 | V2, p. 830

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis

15. ANS: 4

By weighing the dressing before it is applied and after it is removed, the nurse can accurately determine the amount of drainage. Weighing the patient daily would evaluate his overall fluid balance but is not sensitive to fluid loss through the wound. Marking a circle around the wound is useful for determining the extent of drainage seeping out of a wound but it does not provide information how much fluid is draining.

PTS: 1 DIF: Moderate REF: V2, p. 819

KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Synthesis

16. ANS: 4

Pressure ulcers are caused by pressure to an area that restricts blood flow, causing ischemia to underlying tissue. The primary treatment is to relieve the pressure, thus improving blood flow. Elevating the patients left heel off the bed would relieve pressure to this area.

PTS: 1 DIF: Moderate REF: V1, p. 850

KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application

17. ANS: 1

The information obtained from a swab culture is limited because a positive culture may not indicate infection. Chronic wounds are often colonized with bacteria, but this does not require antibiotic treatment. A needle aspiration of the wound would provide more definitive information about whether the wound is infected or not and can be performed by a registered nurse. However, the most accurate wound information is obtained by tissue biopsy performed by a specially trained provider.

PTS: 1 DIF: Moderate REF: V2, p. 825

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application

18. ANS: 3

The goal for any wound is for healing to take place with no complications. Intact skin throughout hospitalization is not realistic with a stage IV pressure ulcer. Limiting pressure to a wound site is incorrect because total pressure relief must be provided to the area. Improved wound drainage before discharge is not a realistic expectation for a stage IV pressure ulcer.

PTS: 1 DIF: Difficult REF: V1, p. 849

KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Synthesis

19. ANS: 2

This patient is at Risk for Impaired Skin Integrity because he is being kept in a sedated state. Thus, he is unable to turn himself to relieve pressure. There is no mention of subcutaneous injuries, ruling out Risk for Infection related to subcutaneous injuries. Impaired Tissue Integrity and Impaired Skin Integrity are also incorrect because there is no supporting evidence for these nursing diagnoses.

PTS: 1 DIF: Moderate REF: V1, p. 848

KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Analysis

20. ANS: 3

A red wound indicates active healing, and the best treatment is gentle cleansing and a dressing that will ensure a clean, moist wound environment. Dbridement is not necessary in this situation because there is no devitalized tissue present.

PTS: 1 DIF: Moderate REF: V1, pp. 836-837 | V1, p. 846

KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application

21. ANS: 3

A hydrocolloid dressing would conform to this area and form a protective layer against friction and bacterial invasion. It would also promote autolytic dbridement of the slough and absorb the exudate from the autolysis. Dry gauze and nonadherent dressing (e.g., Telfa) would cover the wound but would not aid in removing the slough. A wet-to-dry dressing is a form of mechanical dbridement. It would aid in removing the slough but is nonselective; therefore, it could cause damage to healthy tissue as well.

PTS: 1 DIF: Difficult REF: V1, p. 858

KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application

22. ANS: 4

A healing wound contains granulating tissue. Although pain and drainage are indicators of inflammation, infection, bleeding, no pain or drainage at the wound site does not indicate proper healing is occurring. A wound can heal leaving a scar.

PTS: 1 DIF: Difficult

REF: V1, pp. 836-837; higher-order item, answer can be derived from text | V1, p. 841; higher-order item, answer can be derived from text | V1, p. 847; higher-order item, answer can be derived from text

KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application

23. ANS: 1

Alginates are highly absorbent and are appropriate for wounds with moderate to large amounts of drainage. They are ideal for wounds with tunneling, as they will conform to fill the tunnel. Gauze and hydrocolloids have limited absorptive ability. Gauze could adhere to the wound bed and cause trauma when removed. A hydrogel would increase the drainage, with the potential of macerating surrounding skin.

PTS: 1 DIF: Moderate REF: V1, p. 856

KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application

24. ANS: 2

A 35-cc syringe with a 19-gauge angiocatheter is the best choice for irrigation because it will deliver the irrigation solution at approximately 8 psi. The water jet irrigation unit and 5-cc syringe with a 23-gauge needle would deliver the solution above the recommended pressure range of 4 to 15 psi. A bulb syringe is not an appropriate choice because there is an increased risk of aspirating drainage from the wound.

PTS: 1 DIF: Moderate REF: V1, p. 853 | V2, p. 778 | V2, pp. 830-831

KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

25. ANS: 4

To avoid the possibility of cross-contamination, the wound with the least amount of contamination should be treated first, progressing to the wound with the most contamination.

PTS: 1 DIF: Difficult REF: V1, p. 860

KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension

26. ANS: 2

An abdominal binder provides added support to an incision site and decreases the risk of wound dehiscence. A T-binder is used in the perineal area. Steri-Strips and paper tape would not be appropriate in a wound that has intact staples or sutures.

PTS: 1 DIF: Easy REF: V1, p. 860

KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

27. ANS: 3

The patient should be placed on a turn schedule to relieve the pressure. If pressure is not relieved, the wound will worsen. A stage I wound is not open, so a dressing is not warranted. Enzymatic dbridement is used to remove slough or eschar in an open wound. A transparent film dressing would protect the area. However, the primary treatment is to relieve the source of pressure.

PTS: 1 DIF: Moderate REF: V1, p. 850

KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Analysis

28. ANS: 1

Apply heat or cold therapies intermittently, leaving them on for no more than 15 minutes at a time in an area. This helps prevent tissue injury and also makes the therapy more effective by preventing rebound phenomenon. Temperatures should be kept between 59F and 113F (15C and 45C), depending on the type of therapy chosen and what is comfortable to the patient. Temperatures that are colder or hotter than those recommended can damage tissue.

PTS: 1 DIF: Easy REF: V1, p. 861

KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension

29. ANS: 4

Tertiary intention is a technique used when a wound is clean contaminated or dirty (potentially infected). Initially, the wound is allowed to heal by secondary intention, and when there is no evidence of edema, infection, or foreign matter, granulating tissue is brought together and the wound edges are sutured closed.

PTS: 1 DIF: Moderate REF: V1, p. 836

KEY: Client need: PHSI | Cognitive level: Comprehension

30. ANS: 2

Aging skin tends to be drier. Sweat gland activity is diminished. The skins connective tissue, collagen, and elastin are reduced, which means the skin loses firmness and so wrinkles. Skin aging also occurs with exposure to oxygen-free radicals that are waste products from chemical reactions in the body as well as with exposure to certain food and environmental sources. An infants skin is thinner and more permeable to moisture in the environment.

PTS: 1 DIF: Easy REF: V1, p. 832

KEY: Client need: PHSI | Cognitive level: Comprehension

31. ANS: 3

The client at greatest risk for pressure sores is the one with a lack of sensory perception at the site (e.g., quadriplegia). The infant with disruption to the skin from diaper rash is at risk for skin infection but not for a pressure sore. The young adult with diabetes is at increased risk for delayed wound healing but not likely for a pressure sore because he would shift weight in bed and respond to discomfort of pressure on a bony site. The older adult is normally at risk for pressure injury but when mobile, even with an assistive device, the risk is minimal.

PTS: 1 DIF: Moderate REF: V1, p. 832

KEY: Client need: PHSI | Cognitive level: Application

32. ANS: 4

Heat therapy is used to relieve stiffness and discomfort commonly associated with musculoskeletal soreness. Heat causes dilation of the blood vessels and improves delivery of oxygen and nutrients to the tissues. It promotes relaxation and is used to aid in the healing process. Applying heat promotes vasodilation and reduces blood thickness (viscosity) and leaky capillaries, all of which would be harmful to the patient who is actively bleeding. It can lead to a drop in blood pressure. Heat should not be applied to a site with inflammation (insect bite or acute joint injury with swelling) because it can increase edema to the site. A good application for heat therapy is to promote comfort and relaxation to the patient experiencing back pain.

PTS: 1 DIF: Moderate REF: V1, p. 861

KEY: Client need: PHSI | Cognitive level: Application

MULTIPLE RESPONSE

1. ANS: 2, 4

During the inflammatory phase of wound healing, hemostasis and inflammation occur. After an injury, blood vessels constrict to limit blood loss, and platelets migrate to the site and aggregate to stop bleeding. Together, this results in hemostasis. Inflammation follows as a defense against infection at the wound site.

PTS: 1 DIF: Moderate REF: V1, p. 836 | V2, p. 830

KEY: Client need: PHSI | Cognitive level: Recall

2. ANS: 3, 4

The Braden scale is a tool used to predict the risk of developing a pressure sore. Evaluation is based on six areas (indicators): sensory perception, moisture, activity, mobility, nutrition, and friction or shear. The Norton scale is another tool used to assess the risk for pressure ulcers based on the patients physical condition, mental state, activity, mobility, and incontinence. These are the two most used risk assessment tools in the United States. Both of these tools are used to identify persons at high risk of pressure ulcer development. The Waterlow scale is a risk assessment tool used primarily in Britain. FLACC is a pain assessment scale used for children.

PTS: 1 DIF: Moderate REF: V1, p. 845 | V2, p. 830

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall

3. ANS: 1, 3, 4

Wet-to-dry dressings, sharp debridement, and pulsed lavage are all forms of mechanical dbridement. They are nonselective forms of dbridement, which means that healthy tissue as well as devitalized tissue can be removed with their use. Sharp dbridement is a selective form of dbridement. With sharp dbridement, only devitalized tissue is removed.

PTS: 1 DIF: Easy REF: V1, p. 855

KEY: Client need: SECE | Cognitive level: Comprehension

4. ANS: 1, 4

Wounds in highly vascular areas heal more rapidly than wounds in less vascular regions. Wounds that can be stabilized also heal more readily than those in areas of stress. Treatment choices and frequency of dressing changes will be dependent on the condition of the wound, not the location.

PTS: 1 DIF: Moderate REF: V1, p. 846

KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Analysis

COMPLETION

1. ANS:

maceration

By definition, maceration is the softening of a solid (e.g., the skin) by soaking it in a liquid.

PTS: 1 DIF: Easy REF: V1, p. 833 | V1, p. 846

KEY: Client need: PHSI | Cognitive level: Recall

2. ANS: Evisceration

PTS: 1 DIF: Moderate REF: V1, pp. 839-840

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall

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